COMMENTARY

The Reporter Is In: Dr. Sanjay Gupta on Promoting Brain Health in Your Patients

Richard S. Isaacson, MD

Disclosures

February 02, 2021

This transcript has been edited for clarity.

Richard S. Isaacson, MD: On behalf of Medscape, I'm Dr Richard Isaacson, director of the Alzheimer's Prevention Clinic at Weill Cornell Medicine and NewYork-Presbyterian. But who cares about me? We are here with Dr Sanjay Gupta.

Dr Gupta, you've been an inspiration for me. I think a lot of physicians and healthcare professionals have really looked up to you during COVID-19, and before the pandemic you were obviously a trusted voice in medicine. So we appreciate you getting out there and hitting the pavement.

But today we get to talk about one of my favorite subjects, brain health, and how we can live longer and better with a healthy brain. Thanks for being here today.

Sanjay Gupta, MD: Thank you. It's a great privilege for me. And I definitely care about you, Richard, and I appreciate your time very much!

Isaacson: I do a regular column for Medscape where we talk about some of the latest and greatest in brain health, which is a topic you've really been putting your head deep into the literature on for a while now. Compared with 10 years ago, has your mind changed about brain health and the evidence for delaying cognitive decline?

Gupta: I would say that my mind has evolved in terms of how I think about this. I remember having a conversation probably about a decade ago with a colleague who is a neurosurgeon and primarily treats spinal cord injury. We were talking about when we see true growth of new cells. He was seeing it under the microscope in patients who had had some sort of spinal cord injury, but also brain injury or stroke, and obviously in young children and babies whose brains are still forming. The idea that you could see it in healthy brains as well was very intriguing to me. I didn't quite know what to make of it at first. What does that mean, practically speaking, for people?

The other thing was that preclinical Alzheimer's disease was a fascinating concept to me, because we get so used to this idea that we learned on day 1 of medical school, which is: Don't treat the images; treat the patient. So, if you have patients who have objective evidence of Alzheimer's disease yet have no symptoms and are nonclinical, what does that mean? What do we do with that information? How do we translate that into something useful for the population?

Also — and I'm not just saying this because I'm joining you now — your work looking at lifestyle changes was influential for me. I think we've known for some time that these things were likely to make a difference. We would like to see the evidence behind these things. I am a believer that absence of evidence is not always evidence of absence, as we say. But I think your work greatly influenced my thinking as well.

"Three and a half pounds. Yet every learning, every experience, every joy, every pain, every love we've had is somehow woven in there."

Isaacson: Well, I do appreciate that. It's been a long slog, but we've finally started to make some actual progress and move the needle.

As you were discussing, 46 million Americans today have Alzheimer's beginning in their brains, but no symptoms. You and I are both combined med program grads; did you do the 6-year program or the 7-year program?

Gupta: I was the last year of the 6-year program.

Isaacson: I did a 6-year program too. A lot of these programs are switching now, but we're both baby docs, as they say, who did college and med school all together. I graduated at 23 and onward we go.

So, from a young age, we were taught that Alzheimer's is a dementia and that you make the diagnosis when the person has memory loss. But nowadays we know that Alzheimer's disease begins in the brain 20-30 years before that first symptom of cognitive decline. That leaves a whole lot of time for a physician or a healthcare practitioner to jump in and give some patients advice on brain-healthy choices.

You just wrote a book called Keep Sharp: Build a Better Brain at Any Age. I loved reading it and learned a lot, which is awesome. And it's super-easy to read, which is useful because patients need to understand this stuff. What have you learned while writing this book about brain health that you think may translate well to patient behaviors?

Gupta: There were a few things that were really striking, some of which were more of societal observations and some of which were more granular science. One of the things that strikes me, Richard, you will know better than most. There was a real sense from talking to people in the United States and other places around the world that they will do things to optimize heart health, for the lungs, to avoid getting cancer and things like that. However, when it comes to the brain, besides something like wearing a helmet when riding a bike, there wasn't a lot that people really believed could work.

The idea was that the brain is truly a black box inside this hard case of skull, measured only by its inputs and outputs, and the fact that it's hard to observe really made the brain quite mysterious. And it is mysterious. I started my training in neurosurgery in 1993, so I've been doing this for a long time, but — as I'm sure is true for you as well — it's still a wondrous experience to just look at the brain and think, Three and a half pounds. Yet every learning, every experience, every joy, every pain, every love we've had is somehow woven in there. That wasn't so much a learning as a reminder of just how remarkable and wonderful the brain really is. People generally know that.

Then there's this idea that the brain could be optimized in some way. It's true that we use our entire brains, but 10%-20% of our brain is probably used 80%-90% of the time. I've been saying that our brain is kind of like how we've been living our lives during COVID-19. We are at home primarily. We may go to work, to see our kids, to the grocery store or whatever, but that's it. There are all of these underutilized areas of the brain and real estate, which I thought was really interesting. When I started reading some of your work again, and then even going back to earlier cognitive researchers like Herbert Benson, who did work talking about the mind-body connection, some of it was not hardcore science, but it did get at this idea that there are ways to kind of optimize things. I'm not talking about diagnosing disease or treating something, but just using the brain in different ways.

I was struck by that. I started having lots of conversations with people, including my own parents and my kids, about writing this book, only to abandon the project several times after thinking it wasn't something that I was going to be able to explain well. But those were some of the bigger learnings, I think.

Isaacson: The past decade has been such a whirlwind. The 1990s was officially designated "the decade of the brain." But it's really been multiple decades of the brain, because I literally learn something every week that I can apply to patient care the very next day. In the past it would take maybe a few months to learn something new.

So I agree with you. The concept that brain function can be optimized sounds like it's science fiction to both the public and even physicians. I see that every day in my clinical practice. We published a study in late 2019 where patients' cognition was optimized at 18 months after following a risk-reduction paradigm. And there are now multiple randomized controlled trials, as well as our comparative effectiveness research, showing that.

I completely agree that even a decade ago, I don't even know that I would have said we can optimize brain function. Maybe we can stabilize it and that would be the goal; in fact, it would be a great goal. But in that study, we showed that people with mild cognitive impairment — the first symptomatic phase of Alzheimer's disease, with amyloid in the brain and mild symptoms, but who don't yet have dementia — can improve their cognitive function 18 months later. Again, that sounds like science fiction, but the tools are out there.

Of course, don't get me wrong, people have to put in the work. Participants who benefited actually complied with greater than 60% of the 21 different recommendations we gave them. But they did it and they actually optimized for cognition. I think that's a really powerful statement, so I'm really glad you brought that up.

Gupta: It's interesting to have this conversation with you. When we were starting to think about this topic and I was doing some reporting around some of your work — this is besides the book, in our own reporting for news and television — I remember asking, "What is the word we want to use here?" I thought "optimization" was a fair word because it suggests that, as with many aspects of our bodies, we are not doing everything we can to use the function to its greatest extent. It's not to say that we are diagnosing or treating. We were very careful to ask, "Are we actually reversing something as well? Is this a therapeutic or is this like saying we want to optimize function as you might talk about your heart function? For example, I want to increase my ejection fraction, my oxygen utilization, things like that. Can we start to use that sort of language when it comes to the brain?"

It took a long time to get there, and I wanted to be very careful, but I think we felt very, very comfortable saying that. As you know, having read the book and been heavily profiled within it, we caveat the term "reversing" when we use it. If you get to certain stages of dementia or mild to moderate cognitive impairment, what point can you still reverse? Because I think it's so critically important to provide the right level of optimism and hope around this, but not, frankly, to overpromise. This isn't just being conservative, as the medical institution understandably often is. I think this is really about being honest.

Isaacson: I think you hit the nail on the head. I always tell other practitioners who want to do this type of work around brain health, prevention, and risk reduction — whatever word you want to use semantically — you have to promise not to overpromise. Because we can get really excited. We can say that the 2020 report of the Lancet Commission shows that 40% of cases of dementia are preventable based on modifiable risk factors. That's really exciting — 4 out of 10 cases. But on the other side of the coin, 6 out of 10 may not be. If we can delay it by a year or two in those cases, well, that's a victory. But we're not going to have those victories in a lot of people. I agree with you that we have to be really cautious.

For clinicians watching this right now, is there one take-home message you want to leave them with about risk reduction for Alzheimer's disease? They've got their boots on the ground. They're seeing so many patients, maybe 10, 15, 20. They've been time-limited, bruised, and beaten from the COVID pandemic, doing the best they can. But they have a patient sitting in front of them who's at risk. What do you want the message to be?

"...as we give these guidelines to people who are already dealing with this or have loved ones who deal with this, it can be seen as saddling them with some guilt."

Gupta: I thought a lot about that. I do want to touch upon one thing you said earlier, which I think is so important and that clinicians will appreciate. I was having a conversation with a few patients who I interviewed for the book about this exact topic of risk reduction using lifestyle. One of the things they came back to me with — and this is my own learning here and I think it's instructive — is that if you tell people that these types of lifestyle changes can dramatically reduce their risk, with 40% being preventable, it does sometimes make people who are already diagnosed or have a loved one who's been diagnosed feel a little guilty.

They may think, Had I or my loved ones only done these things, maybe I wouldn't be dealing with this. I just bring that up because it was instructive for me, and it's empathetic to remember that as we give these guidelines to people who are already dealing with this or have loved ones who deal with this, it can be seen as saddling them with some guilt. So I just think we have to be careful. Maria Shriver has also pointed this out to me. We don't want to make people feel guilty. We are just learning some of this ourselves, so people shouldn't feel badly if they hadn't been abiding by this. It wasn't thought that their risk factors could actually be modified.

For clinicians, first of all, I think the important idea is that these risk factors can be modified, that lifestyle changes can lead to risk reduction in developing Alzheimer's, and not overpromising that it would reverse moderate symptoms if they've already developed.

And then my general approach has always been to say what those interventions are and then explaining why they might work. For example, one of the things I really dug deeply into was around nourishing the body and nourishing the brain, and how the brain is different. Specifically, I focused on this idea of what some have started calling "type 3 diabetes." This is the idea that your insulin regulation within your brain is so much more sensitive than even the rest of your body. If you had a lot of glucose in your bloodstream and the energy was not being absorbed for whatever reason — because you didn't have enough insulin, you had sensitivity, you had too much body fat, whatever it might be — you could run into a situation where you were eating a lot and the brain was still starving. We all know that decreasing your overall sugar consumption is an important thing, but how do you convey to a patient what it might do for their brain overall?

I found things like that to be really interesting and actionable for people when it came to the idea of first building cognitive reserve. When we used the term "cognitive reserve," I got a lot of pushback from our publishers and even from the television editors, who said, "Is this a term that people even understand? What does it mean? Is that resiliency? How do you specifically build cognitive reserve in the brain?" I thought it was important enough to keep pushing forward on that and even to give strategies in terms of how you do that. An example of this, given to me by one of the neuroscientists we spoke with, was eating with your nondominant hand one night, engaging in things and hobbies that are different from what you normally do, and, even better, hobbies that use your hands, that have a motor cortex component to them as well.

You obviously have to tailor these messages for your patient. But the important ideas are (a) that it can happen and (b) that it's not just the what but the why that you're conveying to your patients. I think that makes a huge difference. Whether it's nourishment, which is the term I use instead of "diet"; whether it's movement, which I say instead of "exercise" — there's a real value of discovery in terms of building the cognitive reserve. It's a fun conversation to have. I think explaining what exactly is happening in this area of the body that is very mysterious to most people makes a huge difference.

Isaacson: I totally agree. In med school, I didn't learn that as the belly size gets larger, the memory center, the hippocampus in the brain, gets smaller. I didn't learn, for example, that women who have visceral fat, belly fat, have a 39% higher likelihood of developing dementia. Is Alzheimer's a metabolic disease? It honestly may be. In a lot of cases I think it really, truly is. So I'm really glad you brought that up.

Dr Sanjay Gupta, thank you so much. You've been so generous with your time. I hope people out there learn more about brain health and read Keep Sharp. And I really appreciate your time.

Gupta: Thank you, Richard. Anytime.

Dr Gupta is a writer, chief medical correspondent for CNN, and associate professor of neurosurgery at the Emory University School of Medicine.

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